JV-290
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
FOR COURT USE ONLY
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
CHILD'S NAME:
HEARING DATE AND TIME:
CAREGIVER INFORMATION FORM
To the current caregiver, preadoptive parent, community care facility, or foster family agency caring for the child: You may
submit written information to the court and you may attend review and permanency hearings. You may use this optional
form to provide written information to the court. Please type or print clearly in ink and submit the original and eight copies of
the form to the court clerk's office at least five calendar days (or seven calendar days if filing by mail) before the hearing. Be
aware that other individuals involved in the case have access to this information. See form JV-290-INFO for instructions on
how to complete this form and file it with the court.
1. a. Child's name:
c. Child's age:
b. Child's date of birth:
2. Caregiver Information (Answer only if you are a caregiver, skip #3.):
RelativeFoster parentb. Type of caregiver:
months.yearsc. The child has been living in my home for (specify):
There is no new or additional information since the last court hearing.
Page 1 of 2
Form Approved for Optional Use
Judicial Council of California
JV-290 [Rev. October 1, 2007]
Welfare and Institutions Code, §§ 366.21(c), (d); 16010(f)(3);
Cal. Rules of Court, rule 5.534(m)
CAREGIVER INFORMATION FORM
There is new or additional information since the last court hearing, as follows (do not include the names of doctors):
Preadoptive parentLegal guardian
www.courtinfo.ca.gov
a. Name of caregiver:
3. Agency or Facility Information (Answer only if you are an Agency or Facility, skip #2.):
c. Telephone number:
Foster family agency d. Type of facility:
months, and in the years
e. The child has been placed with our agency/facility for (specify):
b. Address:
Other (specify):Community care agency
a. Name of agency or facility:
f. Name of person completing form:
g. Hours per week the person completing this form spends with the child (specify):
Title:
h. The information on this form consists of
the observations and recommendations of the person filling out this form.
the observations and recommendations of a group or team made up of the following individuals (specify):
4. Current Status of Child's Medical, Dental, and General Physical and Emotional Health
Other (specify):
current home for (specify):
months.years
hours/week.
CASE NUMBER:
Nonrelative extended family member
(1)
(2)
a.
b.
To keep other people from
seeing what you entered on
your form, please press the
Clear This Form button at
the end of the form when
finished.
CASE NUMBER:
CHILD'S NAME:
8. Current Status of Child's Social Skills and Peer Relationships
9 . Current Status of Child's Special Interests and Activities
10. Other Helpful Information
If you need more space to respond to any section on this form, please check this box and attach additional pages.
Number of pages attached:
Date:
(TYPE OR PRINT NAME) (SIGNATURE OF CAREGIVER OR FACILITY/AGENCY STAFF PERSON
WHO HAS COMPLETED THIS FORM)
JV-290 [Rev. October 1, 2007]
Page 2 of 2
CAREGIVER INFORMATION FORM
12.
7. Current Status of Child's Adjustment to Living Arrangement
There is no new or additional information since the last court hearing.
There is new or additional information since the last court hearing, as follows:
a. The child is a special education student. Date of last Individualized Education Plan (IEP):
b. The child is not a special education student.
JV-290
5. Current Status of Child's Education
There is no new or additional information since the last court hearing.
There is new or additional information since the last court hearing, as follows (do not include the names of schools):
a.
b.
c. I do not know the child's special education status.
a.
b.
a.
b.
a.
b.
There is new or additional information since the last court hearing, as follows:
There is no new or additional information since the last court hearing.
There is new or additional information since the last court hearing, as follows:
There is no new or additional information since the last court hearing.
a.
b.
There is new or additional information since the last court hearing, as follows:
There is no new or additional information since the last court hearing.
11. Recommendation for Disposition (Outcome)
a.
b.
I am recommending the following disposition (outcome):
I have no recommendation for disposition (outcome).
6. Child's Special Education Status
For your protection and privacy, please press the Clear This Form
button after you have printed the form.
Save This Form
Print This Form
Clear This Form
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome